‘Good’ and ‘bad’ doctors - a qualitative study of the Austrian public on the elements of professional medical identity

ABSTRACT Professional identity formation has become a key focus for medical education, but there is still much to learn about how to help students develop their professional identity. At a time when influential concepts such as public- and patient-centered care have become common values, there is little research on the conceptions of the public that trainees might adopt during their training. Defining characteristics of ‘good’ and ‘bad’ physicians can be a starting point when considering how to incorporate aspects of professional behavior into medical curricula. Therefore, this study examined the essential elements of physician identity from the public’s perspective. This study aimed to describe the Austrian public’s viewpoint about the characteristics of ‘good’ and ‘bad’ doctors. Using a qualitative research design, interviews were conducted with the Austrian public (n = 1000, mean age 46.4 ± 15.8 years). Interviews were transcribed verbatim and analyzed via qualitative content analysis. The respondents stated 2078 answers for ‘good’ and 1728 for ‘bad’ doctors. The content analysis produced seven categories: ‘social skills’ (36.3%), ‘professional competence’ (30.2%), ‘personality’ (10.8%), ‘communication’ (6.3%), ‘practice organization’ (5.9%), ‘ethical and moral behavior’ (5.7%), and ‘I do not know, or I have no idea’ (4.9%). The public can help medical students to construct their professional identity by supporting the exploration of and commitment to professional values that society expects of physicians. Ideally, fusing medical expertise with social skills will fulfill the ideal of what the public considers a ‘good’ doctor. This shared definition of a ‘good physician’ has several implications for medical education. Future physicians can benefit from education about the general population’s medical needs as well as personal needs, fears, and concerns.


Introduction
Becoming a medical professional is not only about the accumulation of medical knowledge and skills, but also about core values and essential elements like ethical principles and communication skills; it is also about the acquisition of a new identity -an identity as a physician [1][2][3]. Professional identity formation (PIF) is a multifaceted development consistent with the competencies and values of the medical profession, intended by both medical students and educators, perceived by them and by the public or their future patients [3]. The goal of identity formation is to transform medical students into physicians and prepare them for the needs of the community and society [4].
Medical education characterizes PIF as a dual process: at the individual level, which involves psychological development; and at the collective level, which includes role socialization and participation in the community's work [5]. Until now, medical education has focused on socialization, specifically the influence of experienced professional role models [6], participation in a community or communities of practice [7], and clinical encounters with patients as factors in PIF [8,9].
Bleakley and Bligh suggest relocating physicians' identity construction away from identification with senior physicians as role models to an authentic patient-centered model, 'where sustained early patient contact offers a basis for accelerating the forming of tacit knowledge (scripts, pattern recognition, and encapsulated knowledge) as the basis to clinical expertise' [10]. A person becomes a physician in relation to others: patients, colleagues, and public members. Therefore, roles are external characterizations defined by others. Clinical and nonclinical experiences also impact the development of a learner's medical professional identity through conscious and unconscious pathways [11]. Understanding this process in a way that supports and promotes this identity shift is critical in preparing physicians to work adaptively in evolving systems of care, take advantage of new technologies, and meet changing health care needs [12].
Experience gained from direct encounters with patients and other public members is foundational to a physician's identity [5,9,13]. However, the critical role that patients or the public can play in PIF outside the clinical learning environment has received little attention. Nevertheless, active patient engagement should become an increasingly central component of education to help students explore their role as health professionals [14,15]. Active public and patient involvement (PPI) is an essential part of quality assessment and reporting, priority setting, clinical practice guideline development, and implementation, health technology, comparative effectiveness research, and health governance [16][17][18][19]. In the last few years, PPI increasingly encompassed student selection and admission, curriculum development, course management, faculty development, and program evaluation [18,20]. Therefore, medical professionalism, as seen by the public, should be more central to medical care [15]. It should be a priority in professional life, practice, education, regulation, and research to achieve good medical practice for everybody.
As of now, more knowledge is required to develop students' medical professional identity through comprehensive curricula. However, to take this step, it is necessary to determine which elements and behaviors are associated with the concept of medical professionalism. The way in which societies talk about 'ideal doctors' shapes how medical educators and students understand and implement the process of becoming one [21]. The discussion of identity formation is underpinned by the widespread assumption that there is an ideal 'good doctor' identity that students and trainees are taught and must grow into [22]. The 'ideal doctor' can be perceived differently by the nursing staff [23,24], practicing doctors [25][26][27][28], medical students [2,[29][30][31], the public [25,32,33], or patients [24,26,27]. However, there is limited knowledge about the Austrian public's perspective on the concept of an 'ideal' or 'good' doctor.
To look beyond professionalism as a measurable competency, educators have emphasized the importance of forming a professional identity in which learners 'think, act, and feel like doctors' [3][4][5][6]34]. None of the studies addressed professional identity as perceived by the public. Since identity cannot be observed, we expeced descriptions of behaviors as indicators of an underlying identity structure.
Furthermore, in this study, we assumed that the public views and assesses professional behavior from a different perspective than the medical staff. As we are striving to strengthen the responsiveness to the needs and expectations of the public, we used the term public instead of patient to include people with health problems and healthy people, community members, and laypeople. In doing so, we sought to bridge the gap between 'knowing how to act as a medical professional' and 'acting as a medical professional so that everyone can perceive this professional medical identity'.

Aim
This study aimed to examine the public's perception of doctors' ideal qualities by analyzing their representation of both 'good' and 'bad' doctors. Beyond physicians' particular characteristics, we also investigated whether the 'bad' doctor can be defined as an extension or a contrast to the image of a 'good' one. Therefore, we collected statements from the public about these characteristics. We categorized the statements to obtain a comprehensive description of medical professional identity.

Study design
In this study, we used a qualitative approach with an open-ended questionnaire. The questions were as follows: 'In your opinion, what is a good doctor? In addition, what else do you think makes a good doctor? How would you describe him or her?' and 'In your opinion, what is a bad doctor? In addition, what else do you think makes a bad doctor? How would you describe him or her?' The answers were categorized via content analysis by a psychologist and a physician (JSG and AH).

Data collection
Data were collected through an anonymous, nationwide computer-assisted telephone interview (CATI) with 1000 Austrian citizens. An experienced research institute (Austrian GALLUP Institute) conducted the interviews between February and March 2020. For this purpose, random telephone numbers were generated using the random last digit (RLD) dialing method, which ensures that people not listed in the telephone book are included in the sample. For this study, 80000 randomly generated telephone numbers were available, with 70% mobile numbers and 30% landline numbers. Table 1 shows the dropouts proportional to the interviews. The CATI system sorts the numbers to control the proportion of mobile and landline numbers.
To ensure representativeness, a quota sample was obtained for gender, age, federal state, level of education, and city size. The criteria for representativeness were a sufficiently high number of cases, comparatively small ranges of variation of ± 1.4 to ± 3.2 for a sample of n = 1000 interviews, simple random sampling, and each person had the same chance of becoming part of the sampling.
Exclusion criteria were no consent, unwillingness to participate, or difficulties with the German language that hindered them from understanding or answering the questions. Informed consent was obtained from all participants. The questions had been pretested on a small sample (N = 20). Preliminary data were not included in the subsequent analysis.
The interviews were conducted in German and had an average length of 14 minutes.

Data analysis
Interviews were recorded, transcribed verbatim into electronic form, and anonymized. We subsequently analyzed the transcripts with MAXQDA 2020 (Verbi GmbH) using Mayring's content analysis, a systematic qualitative method for identifying, analyzing, and reporting patterns and themes within data [35].
All responses were grouped into thematic categories. A list of key categories taken from Luthy et al. [36] was used as a template to identify and categorize the responses.
One researcher (JSG) analyzed the transcripts and iteratively developed categories. Simultaneously, a second researcher (AH) interpreted approximately 20% of the material. The coding structure and the emerging conceptual framework were iteratively developed and critically discussed with two more researchers (VSH and HK) until a consensus was reached. Finally, the whole material was re-worked by JSG according to the accepted coding scheme.

Participants
Among the 1000 participants, 51.5% were women and 48.5% were men. Participants had the opportunity to choose which of the following four categories they assigned themselves to female, male, diverse, or I do not want to categorize my gender. On average, female respondents were 48 years (SD = 15.46) and male respondents were 45 years old (SD = 16.07). Age ranged from 18 to 75 years (M = 46.4; SD = 15.8) ( Table 2).

Translation
Translation of the codes and statements into English was based on international standards and principles of good practice for the translation and cultural adaptation [37]. The first author translated the statements into English, taking care to preserve the original meaning. Two colleagues whose native language is German then independently translated this first version backward into German. Translation discrepancies were discussed until a consensus was reached. The retranslation was then compared with the original German-language version, revealing minimal differences, which could be clarified via communicative validation. Then, an English language editing service professionally edited them.

Ethical considerations
After explaining the study objectives, participants gave their consent for interview and recording.
Confidentiality was guaranteed and all responses were anonymized. Participants had the right not to answer questions and could withdraw from the study. As no clinical trial was performed and patients were not involved in this study, the ethical committee of the Medical University of Vienna granted an exemption from the ethics approval requirements. The study protocol was in line with the ethical guidelines of the Declaration of Helsinki on Good Clinical Research Practice.

Results
Overall, 1000 participants gave 3806 single responses. We collected, compared, and coded 2078 answers for 'good' and 1728 for 'bad' doctors. Based on the statements, the content analysis distinguished seven main categories, with some degree of overlap between them: 'personality', 'social skills', 'communication', 'professional competence', 'practice organization', 'ethical and moral behavior', and 'I do not know, or I have no idea'. Figures 1 and 2 are summarizing the responses for the main categories the public considers a 'good' and a 'bad' doctor. Table 3 shows the seven main categories and the considerations how statements were assigned to which category.

Attributes of 'good' doctors
'Social skills' is the largest category and covers 38.6% of all 'good' doctor responses with 806 statements ( Table 4). The answers mainly refer to doctors taking time for consultation and listening carefully to their patients. Doctors who are responsive to complaints, take care, are reliable and dedicated, and interact well are considered 'good'. Statements referring to doctors that are understanding, attentive, helpful, reassuring, and motivating define this category. Respondents mention that doctors should empathize with patients' medical problems and their situations. With 649 statements, the category 'professional competence' comprises 31.1% of all 'good' doctor responses and is thus the second most frequent category ( Table 5). The answers on medical competence mainly refer to proper diagnostic and therapeutic skills, correct, accurate, fast, and efficient diagnostics, and precise and thorough examination. The respondents also emphasize medical competence, flawlessness, and practical skills in their statements. This category includes professional education and training, extensive knowledge, and experience. Some mentions describe 'good' doctors as those who help with recovery, conduct correct and quick treatments and therapies, and treat patients well and painlessly. According to the public, on the one hand, doctors should prescribe correct medication fast, but on the other hand, they should not immediately and not only prescribe hard drugs. Further statements correspond to alternative or holistic medicine and the willingness to refer to other doctors.
The 'personality of a good doctor' consists of 185 'good' doctor quotes and thus comprises 8.9% of all statements about 'good' doctors. It contains personal traits, such as being kind, patient, open, honest, polite, likable, and humorous. The statements refer to doctors who are humane, fond of children, and conscientious. To be a 'good' doctor, according to some, it is also necessary to avoid negative personality traits, such as being a snob or being 'God in white' ( Table 6).
With 129 statements, 'communication' covers 6.2% of all 'good' doctor responses and is, therefore, the fourth-largest category. The main topics in this category are comprehensive explanations with simple conversations and outlooks on treatment possibilities. It includes questioning and answering honestly, openly, and in a way, patients can understand. The interviewees emphasize that communication skills  Personality traits are personal factors that push people toward or away from professional behavior. Personality refers to characteristics of the person that are relatively stable and consistent. The focus is on general personality traits such as 'being nice' and 'polite'.

Social skills
Social skills are dispositions of physical and psychological action; these are action-centered. The difference between social skills and the personality of a good doctor is that skills are about peak performance, whereas personality is about typical behavior. Therefore, this category contains specific behaviors, such as 'listening', and 'responding empathically to patients'. Communication During medical treatment or consultation, communication is one of the central tasks of doctors. They have to listen carefully, understand the needs of their patients, or have them explained to them. At the same time, doctors must be able to explain medical issues adequately themselves. It includes patient-friendly language, answering questions, open communication, and explanations about treatment or medication. Professional competence Professional competence is at the heart of medical practice. Therefore, this includes specialist knowledge, medical skills, and abilities of diagnosis, examination, treatment, healing of diseases, and pain relief. It also contains alternative medical knowledge as a counterpart to academic medicine.

Practice organization
This category includes all tasks not directly related to medical treatment. Doctors manage teams and surgeries; they offer services, such as opening hours, home visits, and night services.

Ethical and moral behavior
The relationship between patient and doctor requires trust and honesty. Therefore, this category includes integrity, confidentiality, and independence from pharmaceutical companies, motivation, and passion for the profession as a doctor. The ability to self-reflect and recognize one's own limits are central. At the same time, this category includes respect for and consideration of population groups, e.g., age, gender, religion, and culture. I do not know or I have no idea Some interviewees indicated that they could not or would not answer the interview questions. Some stated that they did not feel confident to make a judgment or did not have an answer.   can create a friendly conversational atmosphere. Some statements highlight good, competent, and personal advice (Table 7).
With 126 individual statements, the category 'practice organization' comprises 6% of the 'good' doctor. According to the respondents, doctors should be available, reachable, and decisive. This category includes special services such as good opening hours, house calls, and night duties (Table 8).
'Ethical and moral behavior' consists of 109 'good' doctor quotations, which accounts for 5.2% of all statements and is, therefore, the smallest category. This subject includes honesty, integrity, trustworthiness, confidentiality, motivation, and passion for the work beyond financial interests or obligations to the pharmaceutical industry ( Table 9).

Attributes of 'bad' doctors
The largest category of the 'bad' doctor is 'social skills' with 576 statements (32.9% of 'bad' doctor responses). The answers mainly refer to doctors who do not take time for their patients and do not liste attentively. According to the public, social incompetence is due to an arrogant, condescending, preachy, or overly theoretical manner. Doctors who do not respond to the individual, cannot soothe their patients, lack understanding, do not have personal contact, or go into too much detail are perceived as unsuitable. If doctors are not on a par with their patients, do not make eye contact, or do not know or recognize them, their behavior is perceived as disinterest. Social incompetence also includes a lack of empathy or care and the feeling of not being taken seriously (Table 10).
'Professional competence' covers 28.5% of all 'bad' doctor responses with 500 statements and is the second most frequent category (Table 11). Respondents emphasize poor, inaccurate diagnostic and therapeutic skills as well as superficial, unpleasant, or painful examinations. Frequently mentioned statements refer to poor, wrong, too strong, or too   fast medication. Doctors are considered medically incompetent if they lack medical expertise or work too fast and make mistakes. The category also contains statements about mass processing and poor therapies, sloppiness, or symptom treatment. Some people also see the absence of alternative medicine, continuing education and training, or referral behavior as arguments for judging doctors as 'bad'. 'Personality' consists of 226 quotations, which accounts for 12.9% of 'bad' doctor statements. Most answers refer to impatient and stressed doctors. Negative personality traits are characterized by aloofness, unfriendliness, insecurity, overconfidence, rudeness, or superficiality (Table 12).
With 109 individual statements, the category 'ethical and moral behavior' comprises 6.2% of the 'bad' doctor. According to the respondents, a doctor's behavior is perceived as immoral or unethical when it undermines integrity, trustworthiness, confidentiality, and assumed moral attitudes. The category contains the idea of a physician who is only interested in money or works for profit and not out of dedication. Undesirable physicians' features, as indicated by some respondents, thus reduce their patients' trust because they often have financial or other connections to pharmaceutical companies (Table 13).
'Communication' covers 6.2% of all 'bad' doctor responses with 107 statements. The main topics in this category are incomprehensible and insufficient explanations, complicated and incomprehensible language, and unobjective comments. A physician, who does not speak, speaks too little, or initiates superficial conversation, creates a poor conversational atmosphere. Some interviewees highlight that poor communication is due to asking too many questions, not inquiring enough, or avoiding answers (Table 14).
'Practice organization' consists of 99 quotations, which accounts for 5.6% of 'bad' doctor statements and is, therefore, the smallest category. This subject includes organizational deficits and poor accessibility, such as long waiting times for appointments in overcrowded waiting rooms (see Table 15). A few statements mention the equipment of the practice and its structure. According to the respondents, 'bad' doctors are not sufficiently available, have too many patients, and do not offer house calls or night duties.

Discussion
In our study, we investigated the characteristics of 'good' and 'bad' doctors to explore the public's perception regarding the ideal qualities of physicians. Based on the analysis of the interviews, seven categories were identified. Most of the statements refer to either social skill or professional medical competence; these, therefore, seem to be valued qualities of good doctors.
When we look at the most frequent statements of the respondents, we discover the following definitions: An ideal physician could be defined as someone who takes plenty of time to listen attentively to the patients, can respond empathetically and sensitively to their concerns or complaints, and has medical expertise. By contrast, inadequate doctors have no time, do not listen attentively, appear impatient or stressed, treat their conversational partner arrogantly or condescendingly, and are medically incompetent.
The selected characteristics showed that the 'bad' doctor could be described at almost all times as the reverse image of the 'good' doctor. Inadequate doctors were more frequently characterized by their negative personality traits rather than their willingness or ability to communicate. The distinction between 'good' and 'bad' doctors is based on the capability to deal with patients and influence their behavior, and it depends more on skills such as attention, care, empathy, and interest than on medical expertise. Similar results have been obtained in various studies investigating perceptions of the public   •

Has a heart for people
• Has the well-being of the patients in mind 'who has a heart for people'; 'Someone dear to one's heart'; / 'the well-being of the patients is in the foreground'; 'who has the patient's well-being in mind'; 'Strives for the well-being of patients';     [19,23,33,38,39] or patients [36,[40][41][42][43][44][45]. For example, Luthy and colleagues [36] evaluated patients' perceptions of 'good' and 'bad' doctors; they used qualitative content analysis to extract eight characteristics of a 'good' doctor, namely scientific competence, sensitivity to emotions, positive personality traits, coping with each patient, availability, skillful communication, truthfulness, and lack of interest in financial aspects.
The objective of medical education among others is a developed professional identity of an ideal doctor. Achieving this goal requires more than excellent questioning, examining, diagnosing, and treating. Forming a professional identity needs more than operationalizing the sociological view of professionalism; it needs an internalization of professionalism through character development [34].
Our results underline the importance of teaching social skills, as aspects such as attentive communication and patient orientation require specific training to achieve peak performance [46]. The patientphysician relationship, communication, and social skills are essential for well-being and health [47][48][49]. These competencies should be acquired at the undergraduate level to provide a solid foundation for professional identity development [50].
The public has a conception of the ideal doctor within the health system, one who is equipped with the necessary human and professional qualities required for an optimal and effective doctor-patient relationship. This study can be taken as an indication that professional identity formation (PIF) in the context of medical education might be improved if the public perspectives were considered and used to inform and shape medical schools and curricula.  What is the best way to teach aspects like communication, personality, and social skills in terms of professionalism in medical schools? Reflection can be an important driver of personality change, and when we reflect on how we respond to new situations or unforeseen circumstances, this can lead to change [51]. The learning generalization model shows how personality can change through taking on roles such as 'medical student' [52]. Reflection might also help to raise awareness of institutional habits, challenge disempowering discourses, and legitimize identities [51]. Educators can promote this development through encouragement, provision of learning opportunities, and guided practice of principles and techniques [53].
Our data indicate that the public expects more focus on patient-centered values and interpersonal factors. Communication is a procedural skill that should be taught and trained, as this skill only improves with experience. It is crucial to educate and train real-life communication, such as active verbal, non-verbal and genuine listening. It refers to such things as eye contact, gestures, and body movement, but it can also include facial expressions, repetitive movements of the extremities, or vocalizations [54]. In most European countries, this has recently become an essential part of the medical curriculum [55]. However, there should be more guidelines for teaching social or communication skills.  It would also be conceivable to review the entire admission process, as medical educators often have no control over which individuals are admitted to the curricular process.
By adding a psychological development framework to character and behavior perspectives, we can better understand professional identity and professionalism and, more importantly, how the students themselves can influence the process of being able to think, act, and feel like a physician. Then, the professional identity formation moves from the hidden curriculum to the visible one.

Limitations
The strongest aspect of this study is the inclusion of numerous respondents from different social backgrounds. Nevertheless, there are some limitations. First, our data were obtained using quota instead of random sampling. Not all elements of quota sampling are representative of the general population. Therefore, selection bias may have occurred, as there are only a few people with non-Austrian citizenship. As a result, some attitudes are likely to be overrepresented. A second limitation is the translation bias. It might be possible that the translation from German into English is accompanied by a change in meaning.
Third, we did not try to make a difference between a 'good' and an 'ideal' doctor or between a 'poor' and a 'bad' doctor. 'Poor' doctors are seen generally as having good intentions but insufficient knowledge or skills for their job. However, 'bad' doctors, no matter how well-educated, trained, or qualified they may be, have bad, undesirable values and suspicious intentions. Characterizing someone as a 'bad' doctor implies moral deficiencies, even though these may coexist with laudable aspects of medical practice [32].
Our findings may adequately reflect the population's views or their lay perceptions of 'good' medical care and treatment. Nevertheless, our research cannot be applied to all medical schools, medical students, or medical curricula indiscriminately. More comprehensive research would be needed before generalizations can be made.

Conclusion
The involvement of the public in determining which attributes are necessary for good medical care is a positive way of ensuring the importance of such qualities, which combine clinical knowledge and skills with humanitarian values.
Active public involvement should be a central component of health profession education to help students explore their role as health professionals in collaborative, patient-centered practice, and shared decision-making.
Considering that perceived identities in medical education have an impact on the PIF, further research into the PIF process and the development of supporting curricula might be beneficial.
The authors believe that it would be reasonable to carry out further research in which students change their attributes, qualities, competencies, and values during training while knowing the needs and expectations of the public.
If PIF is a focus of medical education, then engagement with professional values, moral concepts, ideas, and goals should be encouraged alongside integration into a community of practice. Community members as mentors could be invaluable allies in this substantial endeavor.
We hope that the public perceptions of 'good' and 'bad' doctors can help support medical educators' efforts to support students' active PIF processes and can be included in discussions leading to changes and developments within medical education programs.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
This research was funded by the medical-scientific fund of the Mayor of the Federal Capital Vienna.

Authors' contributions
JSG was responsible for the study concept and the main contributor to data acquisition. JSG, VSH, and AH were involved in data analyzing and interpreting. JSG translated all categories, codes, and exemplar quotes from German to English. VSH and HK then translated back into German. JSG, VSH, and AH, have been involved in drafting the manuscript and revising it critically for important intellectual content. All authors read and approved the final manuscript.

Availability of data and materials
The datasets used during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate
The Data Protection Commission of the Medical University of Vienna approved this public telephone survey. The commission is responsible for reviewing ethical and anonymous aspects of research protocols. The institutional ethics board of the Vienna Medical University waived the official audit because public telephone surveys do not require approval from the Ethics Committee. There was no possible linkage between the respondents and their answers to the questionnaire. All respondents were explained the survey purpose and provided oral informed consent before the interview started by Austrian GALLUP-Institute interviewers. The study protocol was in line with the ethical guidelines of the Declaration of Helsinki on Good Clinical Research Practice.